Provider Demographics
NPI:1003138116
Name:BEAVERTON FAMILY DENTISTRY
Entity Type:Organization
Organization Name:BEAVERTON FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:H
Authorized Official - Last Name:MOGHIMIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-641-1100
Mailing Address - Street 1:10950 SW BEAVERTON HILLSDALE HWY
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-3003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10950 SW BEAVERTON HILLSDALE HWY
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3003
Practice Address - Country:US
Practice Address - Phone:503-641-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD66831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty